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"Three products alone used to treat advanced prostate cancer were associated with about half of all payments to urologists," writes Robert A. Dowling, MD.
On June 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released their annual update of Open Payments Financial Data (calendar year 2019)(https://www.cms.gov/OpenPayments). The Affordable Care Act , Section 6002, also known as the Physician Payments Sunshine Act, requires that manufacturers of “covered drugs, devices, biologicals, and medical supplies” report payments and other transfers of value to physicians to CMS. It also requires that manufacturers and group purchasing organizations (GPOs) report physician or their family ownership and investments interests.
The requirements stem from a concern that payments to individuals could influence or incentivize behavior, and that making payment data public may mitigate such behavior. It remains unclear if either statement is true, and unclear how anyone—such as patients, hospitals, credentialing entities, payers, CMS, regulators, legislators—is using payments data. The recipients of payments are identified by specialty, making it possible to focus on urology. In this article, I will review some summary information and analysis about the payments to urologists reported under this surveillance program.
In 2019, $10 billion in payments or investment value was reported by 1602 unique companies to physicians, teaching hospitals, and other entities; this is an increase of almost 7% in payments compared with 2018 total. The total amount of general payments to individual physician recipients (n = 615,000) was $2.3 billion. 9246 urologists received a total of $38,568,246 of those general payments to physicians, or 1.65% of the total. The largest single payment to a urologist was $2,457,925.50, and the average payment to a urologist in 2019 was $181.72; average and total payments to urologists have been increasing an average of 5% per year over the past 5 years.
In 2019, 62 urologists each received more than $100,000 (average $300,000 in this subgroup) and collectively represented more than 48% of all payments to urologists (Table 1). As in past years, most of the 2019 payments to urologists came in the form of cash, and were compensation for services other than consulting, consulting fees, food and beverage, and royalty or license, for example, speaking engagements (Tables 2 and 3).
CMS requires manufacturers and GPOs to associate a general payment with a drug, biologic, device, or medical supply where appropriate (Table 4). General payments to urologists associated with devices comprised the largest collective payments, totaling $18,479,093.91, or almost half of all general payments. Payments associated with drugs and biologics totaled almost $10.5 million, significantly less than in 2018; 3 drug manufacturers accounted for about half of total payments in this category. The database also classifies payments into a product category or therapeutic area; payments to urologists came largely from manufacturers who classified their product as urology, oncology, interventional urology, or male health related. Three products alone used to treat advanced prostate cancer were associated with about half of all payments to urologists (associated with a drug/biological product).
The Open Payments program tracks payments associated with ownership interest in 2 different ways. First, some of the general payments to physicians are categorized as “current or prospective ownership or investment interest.” In 2019, $1,159,024 in ownership or investment interest was paid from 8 entities to 48 urologists. Most of these payments appear to come from limited liability companies.
The second way that payments related to physician ownership are reported is by the “value of interest,” defined as “the current cumulative value of ownership or investment interest held by the physician (or the physician’s immediate family members) in the Applicable Manufacturer or GPO as of the most recent feasible valuation date preceding the reporting date.” $1.24 billion of value was reported in 2019 for all physicians, and $21 million (1.69%) of that was attributed to 478urologists from 15 entities. Most of the dollars reported of this payment type are from a single entity totaling $12.9 million and distributed among 256 individual urologists; the value of interest for each urologist in that entity ranges from $1.5 million to $7,000 (mean, $50,000 and median, $37,000) and was primarily held as common stock. Urology ranks eighth among all specialties in total ownership interest dollars in 2019 (Figure).
The final type of payments in the Open Payments program are payments associated with a research study, almost all of which are received by teaching hospitals—not individual physicians. Payments to physicians for 2019 total just $71 million, $391,000 (0.55%) of which went to 408 urologists from 15 manufacturers in an average amount of $7,250. The maximum amount of research payments reported by a single urologist in 2019 was $97,000.
Bottom line: General payments from manufacturers to urologists in 2019 reported to and by CMS under the Sunshine Act are consistent with past years, represent an appropriately small fraction of general payments to all physicians, and average less than $200 per urologist. Most of these payments are from device manufacturers, and payments are concentrated in just a handful of individual companies, drugs, devices, physician recipients, and disease states. Prostate cancer (drugs), BPH (devices), and overactive bladder (drugs) continue to be associated with most of the collective payments in the specialty. Transfers of value classified as “ownership interest” are a small fraction of the 2019 general payments, and cumulative value and interest appears to be held in manufacturers or GPOs by urologists in the same average amount as all physicians. The majority of urologists appear in the payment data, but payments are generally small.
Dowling is the president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large, metropolitan single-specialty urology group in Fort Worth, Texas.